Fillable K-8 FULL STEAM AHEAD 2021 Summer Registration Form

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K-8 FULL STEAM AHEAD 2021 Summer Registration Form

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Revised: 4/06/2021
K-8 FULL STEAM AHEAD
2021 Summer Registration Form
Current School: _____________________________________ 2021-2022 SY School: ____________________________________
1. Student Information (Please PRINT student name exactly as it appears on the birth certificate)
Legal Last Name:
Legal First Name:
Full Middle Name:
Date of Birth (MM/DD/YYYY)
Matric #:
Gender:
☐ Male
☐ Female
2. Contact / Residential Information
Name as you would like it to appear on correspondence ( example: Mr. & Mrs. John Doe):
Phone Number:
( ) ☐Home ☐Work ☐Cell
Mailing Address: Unit # City Zip Code
Student Residential Address (write SAME if same as mailing address): Unit # City Zip Code
3. Parents / Guardians - Must be Legal Guardians – all others should be listed as Emergency Contact below
1st Contact
Relationship: ☐Mother ☐Father ☐Other Legal Guardian (please specify) ___________________________________
Last Name:
Home Phone:
Address (write SAME if same as Student Residential Address):
Employer:
Work Phone:
Cell Phone:
Email:
Is an Interpreter needed? ☐Yes ☐No
If yes, which language?
_____________________________________
2nd Contact
Relationship: ☐Mother ☐Father ☐Other Legal Guardian (please specify) ___________________________________
Last Name:
Home Phone:
Address (write SAME if same as Student Residential Address):
Employer:
Work Phone:
Cell Phone:
Email:
Is an Interpreter needed? ☐Yes ☐No
If yes, which language?
_____________________________________
4. Emergency Contact (Persons who will care for / pick up student if parent cannot be reached) – must be over 18
Relationship: ☐Stepparent ☐Grandparent ☐Friend ☐Other ___________________________________
Name:
Home Phone:
Work Phone:
Cell Phone:
☐ Interpreter needed?
Language ______________
Relationship: ☐Stepparent ☐Grandparent ☐Friend ☐Other ___________________________________
Name:
Home Phone:
Work Phone:
Cell Phone:
☐ Interpreter needed?
Language ______________
Relationship: ☐Stepparent ☐Grandparent ☐Friend ☐Other ___________________________________
Name:
Home Phone:
Work Phone:
Cell Phone:
☐ Interpreter needed?
Language ______________
Is there anyone that may NOT pick up your child? (Name): _______________________________________________________________
If so, does your child recognize this person and know they can’t leave with them? (circle) ☐YES ☐NO
Page 1 of 2 ->
Continued on Back
Revised: 4/06/2021
K-8 FULL STEAM AHEAD
2021 Summer Registration Form
Current School: _____________________________________ 2021-2022 SY School: ____________________________________
5. Medical Information
Insurance: ☐None ☐ Yes (Name of Insurance: ____________________ ☐AHCCS ) Physician: ___________________ Phone #: ________________
Medications: ________________________________________________________________________________________________________________
Allergies: ☐Seasonal ☐Medication allergies ____________ ☐Bee ☐Insect ☐Food________________ ☐Other ________________
☐Requires EpiPen
Emergency Care: In case of serious illness or injury and a parent/guardian cannot be reached, I consent for my child to be taken to a hospital,
by ambulance if necessary, for medical care. TUSD will not be responsible for any costs of such not covered by insurance.
SIGNATURE OF PARENT/GUARDIAN: ________________________________________________
6. Special Classes and Accommodations
Please check below any special classes or programs the student has participated in:
☐English Language Development
☐Gifted/Accelerated Program
☐504 Plan - Please provide a copy
☐Special Education
☐Resource ☐Self-Contained ☐Speech Therapy ☐Occupational/Physical Therapy ☐Other
☐Student has a current IEP - Please provide a copy
By signing this form, you indicate the desire for your child to participate in the Summer Program. You also indicate that you
understand that this is an academic and enrichment program, not "child care." You should discuss with your child that
violations of program rules may result in their withdrawal from the program.
I understand that space in program is limited and my child MUST attend the program regularly. If my child has unexcused
absences, they may not be allowed to continue in the program.
_____________________________________________ ____________ ______________________________
Signature of Parent/Guardian Date Relationship to Student
Page 2 of 2
Student Last Name: _____________________________________ Student First Name: ____________________________________
How will your child leave school? Day Care pick-up arrangements must be made by parents.
☐Walk (circle one): alone or accompanied
☐Pick-up
☐Other: explain___________________________________________________________
Students must meet eligibility guidelines as listed in Board Policy EEA (please see the TUSD website).
Parents of students who live outside of TUSD district boundaries are responsible for transportation.
Eligible students who need an alternate address must fill out an Alternate Address Form. Approval is contingent on existing bus routes.
If eligible, will this student ride the bus?
☐Yes ☐No
May your child use the internet in class? ☐Yes ☐No
May we use your child’s photograph/video in promotional material? ☐Yes ☐No
7. Transportation
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K-8 FULL STEAM AHEAD 2021 Summer Registration Form

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Completed 15 April 2021

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